Referral Form

    Referrers Details

    Referring Authority

    Referring Team Address

    Name of Social Worker/Health Worker

    Contact Telephone Number

    Email Address

    Name of Manager

    Contact Number

    Email Address

    Service User Details

    Service User Name

    Service User Address

    Gender

    Date of Birth

    Legal Status

    Ethic Origin

    Religious Needs

    NI Number

    Next of Kin

    Contact Address

    Relationship to Service User

    Contact Telephone Number

    GP Name

    GP Address

    GP Contact Number

    Brief Background Information Please include any diagnosis

    Communication. Are there any issues around communication that we need to be aware of?

    Health and Personal Care Needs

    Details of any Physical and/or Mental health Issues

    Medication Details. Please include frequency and route as well as assistance required

    Personal Hygiene. include details of assistance required with washing toileting and continence and Dressing

    What are the contact arrangements with family/significant others

    Other Health Agencies involved and Contact Details

    Daily Living Skills. Please identify the level of assistance required with cooking, cleaning, laundry, shopping and budgeting

    Has the Service User got any behavioural issues, ie violent, aggressive or self-harm and/or any other behavioural issues that you feel that we need to be aware of?

    Has the Service User any criminal convictions or current charges against them? (if yes, please give details)

    Are there any issues of alcohol and/or substance misuse? (if yes, please give details)

    Are there any issues that we should be aware of in relation to allegations against staff? (if yes, please give details)

    What is the Service Users view about a placement with Hengoed Park Ltd?

    Has the Service User had funding agreed in principle? When would want the placement to start?

    Will the Service User require us to supply accommodation?

    Are there any other Agencies apart from Health Agencies involved with the Service User? (if yes, please give details)

    Is there any other information that we need to be aware of?

    Please supply any reports that you feel may be appropriate for the assessment for this referral.

    Referral Contact
    Deputy Manager
    Telephone: 01691 650454